<table style="margin: 10px 15px 10px 15px;">
	<tr>
		<td width="145">Tanggal Terima Dokter</td>
		<td>&nbsp;</td>
		<td width="295"><input name="nama" type="text" class="input2" id="nama" maxlength="50"/></td>
		<td width="145">Jenis Layanan</td>
		<td>&nbsp;</td>
		<td><input name="nama" type="text" class="input2" id="nama" maxlength="50"/></td>
	</tr>
</table>